New Guidelines For Osteoarthritis - What Do They Mean?

Osteoarthritis is the most common type of arthritis and the leading cause of chronic musculoskeletal pain and limited mobility in older people worldwide.

It is a disease that causes cartilage in weight-bearing areas such as the neck, low back, hips, knees, and the base of the thumbs to deteriorate and wear away.

Since it is so common, many treatments have been advocated. Some treatments work and others don't. However, the sheer number of claims of efficacy can be overwhelming to both physicians as well as patients.

Guidelines are often created by various organizations in medicine to help both the patient as well as the physician arrive at decisions. These guidelines are formulated to let the physician and patient know what types of diagnostic criteria or treatment methods have enough evidence behind them to be recommended for use.

A new set of treatment recommendations for knee and hip osteoarthritis have been released by a scientific organization, the Osteoarthritis Research Society International (OARSI).

These are evidence-based recommendations - meaning they have the power of scientific data backing them up. A subcommittee of OARSI was given the task of coming up with specific guidelines to help clear the confusion and clutter surrounding what really works and what doesn't for osteoarthritis of the hip and knee.

The goals of the committee were (1) to review all of the published national and international treatment guidelines together with the more recent evidence from clinical trials and (2) to produce a single set of up-to-date, evidence-based recommendations for the worldwide treatment of knee and hip osteoarthritis.

The guidelines were accompanied by "grades", ie. percentages, to indicate how much evidence was behind each criterion.

The first of OARSI's 25 evidence-based recommendations was that that best treatment requires both non-drug and drug modalities. The remaining 24 recommendations fall into three categories - non-drug, drug, and surgical.

The following are the recommendations:

Non-drug - These 11 recommendations include education and self-management (97%); regular telephone contact (66%); referral to a physical therapist (89%); aerobic, muscle strengthening and water-based exercises (96%); weight reduction (96%); walking aids (90%); knee braces (76%); footware and insoles (77%); thermal modalities [heat or cold] (64%); transcutaneous electrical stimulation (58%); and acupuncture (59%).

Drug - These eight recommendations include acetaminophen (92%); non-selective and selective oral nonsteroidal anti-inflammatory drugs (NSAIDs)(93%); topical NSAIDs and capsaicin (85%); intraarticular injections of corticosteroids [joint injections of "cortisone"](78%); intraarticular injections of hyaluronans [joint injections of various lubricants](64%); glucosamine and/or chondroitin sulphate for symptom relief (63%); glucosamine sulphate, chondroitin sulphate and/or diacerein for possible structure-modifying effects (41%); and the use of weak opioids and narcotic analgesics for the treatment of refractory pain (82%).

Surgical - These five recommendations include total joint replacement (96%); unicompartmental knee replacement (76%); osteotomy and joint preserving surgical procedures (75%); joint lavage and arthroscopic debridement in knee OA (60%); and joint fusion as a salvage procedure when joint replacement had failed (69%).

According to Dr. Francis Berenbaum, president elect of OARSI and a faculty member in the Department of Rheumatology at Pierre & Marie Curie University, APHP Saint-Antoine Hospital in Paris, "Our goal was to make these guidelines as simple as possible so that healthcare providers could determine which therapies would be most useful for an individual patient."

In recent years, there has been a decline in the use of NSAIDs by physicians because of concerns related to the potential for causing gastrointestinal side effects and the possible cardiovascular risks associated with these drugs.

However, OARSI committee members found that NSAIDs are often effective pain relievers and their short-term use should be considered on a case-by-case basis and not as a long-term option.

The guideline committee was made up of experts from six countries, including 11 rheumatologists, two primary care physicians, one orthopedic surgeon, and two experts on evidence-based medicine.

While these guidelines are helpful in regards to current therapies, there are weaknesses.

For example, research into osteoarthritis is constantly advancing and newer types of therapies exist for which there is still insufficient evidence to say whether they are effective or not.

An illustration might be cold laser where insufficient numbers of well-controlled clinical trials exist to say for sure whether it works and how well.

Second, one therapy, arthroscopic debridement has much evidence supporting its use, yet payers such as CMS (Medicare) will not pay for it citing the very few studies that don't show benefit as their evidence.

Also... the guidelines are just that. They don't say whether a given treatment will work for a specific individual.

Finally, there are cutting edge therapies such as stem cells and the use of platelet rich growth factors which show a lot of promise but for which it is much too early to know how effective they will be.

So... stay tuned!

Nathan Wei, MD, FACP, FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland ( http://www.aocm.org ). He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and consultant to the National Institutes of Health. For more info: Arthritis Treatment

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